Free Consent to Collect Fees  - West Virginia

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA _____________________________________ _____________________________________ _____________________________________ _____________________________________ (Full Name and Prison Number of Plaintiff) V. _____________________________________ _____________________________________ _____________________________________ (Names and Official Titles of Each Defendant) CONSENT TO COLLECTION OF FEES FROM TRUST ACCOUNT I, _____________________________, #_____________, hereby consent for the appropriate prison officials to withhold from my prison account and pay to the Clerk of Court for the United States District Court, at Elkins, West Virginia, an initial payment of 20 percent of the greater of the following choices: (a) OR (b) The average monthly balance in my account for the six month period immediately preceding the filing of the complaint. The average monthly deposits to my account for the six month period immediately preceding the filing of the complaint. Civil Action No.___________________ (To be Assigned by Clerk of Court)

I further consent for the appropriate prison officials to collect from my account, on a continuing basis each month, an amount equal to 20 percent of each month's income. Each time the amount in the account reaches $10.00, the Trust Officer shall forward the interim payment to the Clerk's Office in Elkins, West Virginia, until such time as the $350.00 filing fee is paid in full. By executing this document, I also authorize collection on a continuing basis of any additional fees, costs, or sanctions imposed by the United States District Court for the Northern District of West Virginia. _____________________________________ Date ____________________________________ Signature of Plaintiff

United States District Court

Northern District of West Virginia